This document discusses the buttonhole cannulation technique for vascular access in hemodialysis patients. It provides a history of the technique, beginning in the 1970s in Poland. Early experiences in the US showed benefits like reduced pain, infiltration, and hematoma rates compared to rope-ladder cannulation. The technique involves creating fibrous tracts at constant needle insertion sites using repeated cannulation with sharp then blunt needles. Correct technique includes proper site selection, needle angle/depth, disinfection, and complete scab removal to prevent infection. Larger US studies are still needed to better evaluate risks and benefits.
Buttonhole Cannulation Technique Power PointKelley Stanley
The document discusses the buttonhole cannulation technique for vascular access in dialysis patients. It provides background on dialysis patients and costs in the US. The buttonhole technique creates fixed puncture sites in an arteriovenous fistula to reduce complications from cannulation. The literature review found the technique reduces pain and complications compared to the rope-ladder technique and has been used successfully in Europe for over 30 years. The document proposes evaluating the buttonhole technique for reducing cannulation pain, anxiety, and complications compared to the rope-ladder technique in outpatient dialysis clinics.
Medcrave Group - Open Locked Nailing Using an Expandable NailMedCrave
A retrospective study was performed using the hospital records. The mechanism of injury, the time between injury and surgery, blood transfusion requirements, blood loss, surgical times, time taken to weight bear (for the femoral/
tibial fractures), time for commencement of upper limb use (for humeral fractures), complication rates and the average follow up times were documented. Fifty-seven long bone fractures in 57 patients were included in this study. Complete results including preoperative X-Rays were available for 27 patients. In 30 cases, the actual X-Rays were not located but documentation by the treating surgeons was available.
This document summarizes a case report of spontaneous fragmentation of a double J ureteral stent in a 70-year-old patient with a single kidney. The patient had undergone a right nephrectomy two years prior for kidney stones and had a double J stent placed, but did not return for follow up. He presented with flank pain and was found to have the stent fragmented into three pieces. The fragments were extracted endoscopically with ureteroscopy. Stent fragmentation is a rare but serious complication, and this case highlights the importance of patient education and follow up after stent placement.
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTUREAVATAR
This document discusses the use of stenting to maintain vascular patency for hemodialysis access and whether it will be the future standard. It notes that while stenting is established for coronary arteries, its role for arteriovenous fistulas (AVFs) and grafts (AVGs) is still controversial. The document reviews several studies that showed no benefit or increased complications from stenting AVFs/AVGs compared to angioplasty alone. However, it also discusses some limited evidence that covered stents or stents placed in specific situations like central venous stenosis may improve patency compared to angioplasty. Overall, the document questions whether stenting will become the standard given the lack of strong evidence, complications risks
This study compared outcomes of patients undergoing either laser ablation (PiLaT technique) or Limberg flap (LF) surgery for primary pilonidal sinus. 200 patients were randomized to each group. Results showed PiLaT had significantly shorter surgery time, less post-op pain, earlier return to daily activities, higher patient satisfaction, and no recurrences at 2-month follow-up compared to LF surgery. The authors conclude PiLaT is an effective treatment that may be preferred over LF due to benefits of less pain/tissue loss.
This document discusses balloon-assisted coiling techniques for treating aneurysms. It notes that balloon-assisted coiling provides better immediate and follow-up occlusion rates compared to standalone coiling, though it may carry a higher risk of complications compared to standalone coiling. The document reviews the history and uses of balloon-assisted coiling, complications, techniques for different aneurysm situations, outcomes data on occlusion rates, and debates around its appropriate use compared to standalone coiling and stent-assisted coiling.
This study evaluated the results of a hemorrhoidal laser procedure (HeLP) in 120 patients with grade 2-4 hemorrhoids over a 1-year period. Patients underwent HeLP and were divided into groups based on their hemorrhoid grade. Results found that while operation times were under 20 minutes for all groups, grade 4 hemorrhoids had higher rates of postoperative complications and recurrence compared to lower grades. The study concluded that HeLP is an effective treatment, though more large-scale studies are needed to further evaluate outcomes.
Dr. Iyad Feteih presents information on the history and development of inferior vena cava (IVC) filters. The document discusses early surgical methods of IVC interruption and their complications. It then summarizes the development of endoluminal IVC filters beginning with the Mobin-Uddin umbrella in 1967 and the iconic Greenfield filter in 1973. The document provides details on various commercially available IVC filters from companies such as Bard, Cook Medical, Cordis, and Crux Biomedical including specifications, clinical trial results, and complications.
Buttonhole Cannulation Technique Power PointKelley Stanley
The document discusses the buttonhole cannulation technique for vascular access in dialysis patients. It provides background on dialysis patients and costs in the US. The buttonhole technique creates fixed puncture sites in an arteriovenous fistula to reduce complications from cannulation. The literature review found the technique reduces pain and complications compared to the rope-ladder technique and has been used successfully in Europe for over 30 years. The document proposes evaluating the buttonhole technique for reducing cannulation pain, anxiety, and complications compared to the rope-ladder technique in outpatient dialysis clinics.
Medcrave Group - Open Locked Nailing Using an Expandable NailMedCrave
A retrospective study was performed using the hospital records. The mechanism of injury, the time between injury and surgery, blood transfusion requirements, blood loss, surgical times, time taken to weight bear (for the femoral/
tibial fractures), time for commencement of upper limb use (for humeral fractures), complication rates and the average follow up times were documented. Fifty-seven long bone fractures in 57 patients were included in this study. Complete results including preoperative X-Rays were available for 27 patients. In 30 cases, the actual X-Rays were not located but documentation by the treating surgeons was available.
This document summarizes a case report of spontaneous fragmentation of a double J ureteral stent in a 70-year-old patient with a single kidney. The patient had undergone a right nephrectomy two years prior for kidney stones and had a double J stent placed, but did not return for follow up. He presented with flank pain and was found to have the stent fragmented into three pieces. The fragments were extracted endoscopically with ureteroscopy. Stent fragmentation is a rare but serious complication, and this case highlights the importance of patient education and follow up after stent placement.
IS STENTING TO MAINTAIN VASCULAR PATENCY GOING TO BE THE FUTUREAVATAR
This document discusses the use of stenting to maintain vascular patency for hemodialysis access and whether it will be the future standard. It notes that while stenting is established for coronary arteries, its role for arteriovenous fistulas (AVFs) and grafts (AVGs) is still controversial. The document reviews several studies that showed no benefit or increased complications from stenting AVFs/AVGs compared to angioplasty alone. However, it also discusses some limited evidence that covered stents or stents placed in specific situations like central venous stenosis may improve patency compared to angioplasty. Overall, the document questions whether stenting will become the standard given the lack of strong evidence, complications risks
This study compared outcomes of patients undergoing either laser ablation (PiLaT technique) or Limberg flap (LF) surgery for primary pilonidal sinus. 200 patients were randomized to each group. Results showed PiLaT had significantly shorter surgery time, less post-op pain, earlier return to daily activities, higher patient satisfaction, and no recurrences at 2-month follow-up compared to LF surgery. The authors conclude PiLaT is an effective treatment that may be preferred over LF due to benefits of less pain/tissue loss.
This document discusses balloon-assisted coiling techniques for treating aneurysms. It notes that balloon-assisted coiling provides better immediate and follow-up occlusion rates compared to standalone coiling, though it may carry a higher risk of complications compared to standalone coiling. The document reviews the history and uses of balloon-assisted coiling, complications, techniques for different aneurysm situations, outcomes data on occlusion rates, and debates around its appropriate use compared to standalone coiling and stent-assisted coiling.
This study evaluated the results of a hemorrhoidal laser procedure (HeLP) in 120 patients with grade 2-4 hemorrhoids over a 1-year period. Patients underwent HeLP and were divided into groups based on their hemorrhoid grade. Results found that while operation times were under 20 minutes for all groups, grade 4 hemorrhoids had higher rates of postoperative complications and recurrence compared to lower grades. The study concluded that HeLP is an effective treatment, though more large-scale studies are needed to further evaluate outcomes.
Dr. Iyad Feteih presents information on the history and development of inferior vena cava (IVC) filters. The document discusses early surgical methods of IVC interruption and their complications. It then summarizes the development of endoluminal IVC filters beginning with the Mobin-Uddin umbrella in 1967 and the iconic Greenfield filter in 1973. The document provides details on various commercially available IVC filters from companies such as Bard, Cook Medical, Cordis, and Crux Biomedical including specifications, clinical trial results, and complications.
Tips and tricks to site and maintain nerve cathetersAmit Pawa
This lecture was given on Friday 13th September 2019 at the annual congress of the European Society of Regional Anaesthesia in Bilbao and Spain. The talk was also contributed to by the Twitter Community. Strategies and techniques to site, secure and maintain perineural nerve catheters is discussed
Balloon Assisted Coiling in Ruptured Cerebral AneurysmsDr Vipul Gupta
This document discusses balloon-assisted coiling techniques for treating ruptured cerebral aneurysms. It begins by outlining the historical use of balloons to treat broad-neck aneurysms using the "remodeling technique." It then provides details on techniques such as balloon selection and placement, aneurysm types best suited for different techniques, and potential complications. The conclusion is that balloon-assisted coiling is a versatile technique that does not increase complications compared to standalone coiling and can achieve better aneurysm occlusion, especially for difficult ruptured aneurysm cases.
Stent assisted reconstruction of difficult aneurysms in acute subarachnoid he...Dr Vipul Gupta
This document summarizes the experience of a single center in using stent-assisted reconstruction to treat difficult aneurysms in patients presenting with acute subarachnoid hemorrhage. It describes treating 35 aneurysms in 33 patients that were not amenable to standard coiling, balloon-assisted coiling, or surgery. Stent placement was used to support the neck of wide-neck or dissecting/blister aneurysms to avoid coil protrusion. Most patients (28 of 33) had good outcomes, while 2 had management morbidity and 3 died. The results demonstrate stent-assisted coiling is a viable option for challenging aneurysms in acute subarachnoid hemorrhage cases.
This study evaluated 52 cases of pediatric peritonitis treated via laparotomy over 5 years at a hospital in Nigeria. The most common cause of peritonitis was found to be typhoid intestinal perforation (48% of cases). Other common causes included ruptured appendix (17.3% of cases) and perforated intussusception (15.4% of cases). Post-operative complications occurred in 46.2% of patients, with surgical site infection being most common (23.1% of cases). The mortality rate was 13.5%. The study concludes that typhoid intestinal perforation is a major cause of peritonitis in children in this setting.
This document discusses new therapies for unruptured intracranial aneurysms, focusing on flow diverters. It provides background on flow diverters and how they work. The initial experiences with the Pipeline flow diverter are summarized from early clinical trials. Current controversies and limitations are discussed, including delayed aneurysm ruptures after treatment and questions around antiplatelet therapy. Ongoing studies are exploring real-world experiences to better understand safety and long-term outcomes of flow diverters.
This study investigated the clinical efficacy and safety of uniportal video-assisted thoracoscopic bronchial sleeve lobectomy (BSL) in 5 patients with central lung cancer. The results found that the BSL procedure was successfully completed in all 5 patients without severe complications. Key findings included an average operation time of 254 minutes, average blood loss of 116 ml, average hospital stay of 9.2 days, and no postoperative recurrence or metastasis during follow-up periods ranging from 3-19 months. The study concluded that uniportal video-assisted thoracoscopic BSL is a safe and minimally invasive treatment for central lung cancer.
This case report describes an unusual method for removing a plastic bead that had been aspirated into the tracheobronchial tree of a 9-year-old boy. Conventional bronchoscopic techniques using forceps were unsuccessful at removing the bead, which was located in the left lower lobar bronchus. A Fogarty embolectomy catheter was inserted through the bead's central hole and its balloon was inflated to grasp the bead. The catheter and bead were then removed together through the rigid bronchoscope, successfully retrieving the foreign body without requiring surgery. This creative use of a Fogarty catheter demonstrates how available tools can be adapted based on the shape and location of an aspirated foreign body.
Methods: Retrospectively, the file records of the patients who underwent sleeve gastrectomy were examined. Demographic features, Body Mass Index (BMI), the mouth opening, Mallampati score, thyromental distance, sternomental distance, neck circumference measurements and videolaryngoscopic examination results were recorded Results: In a total of 140 consecutive patients (58 male, 82 female) were included in the study. The mean age of the study participants was 35.40 ± 9.78 and the mean BMI of the patients was 44.33 ± 7.52 kg/m2
. The mean mouth opening of the patients was 4.82 ± 0.54 cm
and the mean neck circumference was 43.52 ± 4.66 cm. The mean thyromental distance was 8.02 ± 1.00 cm and the mean sternomental distance was16.58 ± 1.53 cm. Difficult intubation was determined in 8 (5.7%) patients. In logistic regression analysis, age (p : 0.446), gender (p : 0.371), BMI (p : 0.947), snoring (p : 0.567), sleep apnea (p : 0.218), mouth opening (p : 0.687), thyromental distance (p :0.557), sternomental (p : 0.596) and neck circumference (p : 0.838) were not the independent predictors of difficult intubation. However, Mallampati score (p : 0.001) and preoperative direct laryngoscopy findings (p : 0.037) performed in outpatient clinic were the significant
predictors of difficult intubation. Interestingly, all patients with grade 4 laryngoscopy findings had difficult intubation.
This study compared outcomes of laparoscopic appendectomy versus open appendectomy in 68 patients with acute appendicitis. Patients were divided into two groups - Group I underwent laparoscopic appendectomy while Group II underwent open appendectomy. The time to start oral feeding and average hospital stay were shorter in the laparoscopic group compared to the open group. Post-operative wound infections and abscesses were also less common in the laparoscopic group. The study concluded that laparoscopic appendectomy is an effective treatment for acute appendicitis compared to open appendectomy.
This study assessed the efficacy of different surgical techniques (open surgery, percutaneous nephrolithotomy [PNL], and retrograde intrarenal surgery [RIRS]) for treating kidney stones. 102 patients undergoing kidney stone surgery were divided into the three treatment groups. The mean stone burden, operative time, length of hospital stay, and residual stone rates were compared between groups. Complications like fever, infection, urine leakage and persistent pain were also assessed. PNL and RIRS had lower stone burdens, shorter operative times, shorter hospital stays, and fewer complications compared to open surgery. PNL and RIRS were found to be safer and more effective treatments for kidney stones than open surgery.
A comparative study of the effectiveness of Rubber band ligation and suture l...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Is routine thromboprophylaxis warranted in all patients of tibial fracture ma...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
This document discusses the debate around whether endovascular or surgical interventions should be the first option for treating critical limb ischemia in the lower extremities. It presents data on patency rates from studies comparing percutaneous angioplasty and stenting to femoral-popliteal bypass. It also summarizes studies reporting outcomes of endovascular and surgical procedures for various levels of the leg vasculature. The overall conclusion is that an endovascular-first approach is reasonable for appropriately selected patients, as it is not associated with worse outcomes compared to initial surgery.
This document provides instructions for central venous catheterization of the subclavian vein. It describes the indications, contraindications, necessary equipment, patient preparation, ultrasound guidance, procedure steps, potential complications, and references for central venous catheterization of the subclavian vein. The subclavian vein is the preferred site according to recent evidence. Ultrasound can help with placement despite bony landmarks. Key steps include identifying anatomic landmarks, local anesthesia, inserting the needle at a 30 degree angle, obtaining venous access, introducing the guidewire, dilating the vein, advancing the catheter over the wire, and securing the line. Potential complications include pneumothorax, hemothorax, and infection.
This study evaluated the experiences and outcomes of 150 patients who underwent single incision laparoscopic cholecystectomy (SILC) between 2009-2011. Two different techniques were used for the single incision procedure. The median operative time was 29 minutes. Patients were discharged after a median hospital stay of 1.33 days. Five patients developed superficial wound infections. Port site hernias developed in 5 patients within 6 months of surgery. No other major complications occurred. The study concluded that SILC is a safe procedure that can be performed successfully with conventional laparoscopic instruments and may provide advantages of reduced postoperative pain and improved cosmetic outcomes compared to traditional laparoscopic cholecystectomy.
Background: Distal femur fractures make up 6 to 7% of all femur fractures. Various plating options for distal femur fracture are conventional buttress plates, fixed-angle devices, and locking plates. This study was planned to evaluate and explore locking compression plate fixation in distal end femur fractures which is expected to provide a stable fixation with minimum exposure, early mobilization, less complications and a better quality of life.
Methods: The study was conducted as prospective clinical study in 20 skeletally mature patients with x-ray evidence of distal femur fracture fulfilling inclusion and exclusion criteria, operated with distal femur LCP plating. Patients were assessed radiologically and classified according to distal femur fracture classification and outcome graded as excellent, good, fair and poor based on Lysholm Knee Score.
Results: Out of 15 excellent outcome cases, 3 cases were type A1 fracture, 1 case had type A3, 2 cases had type B1 and B2 each, 5 cases had type C2 and 2 cases had type C3 fracture. 1 case with good outcome was type C3. 1 case with fair outcome was type B2. While 3 cases with poor outcome were type A1, A2 and C3.
Conclusions: The DF-LCP is an ideal implant to use for fractures of the distal femur. However, accurate positioning and fixation are required to produce satisfactory results. We recommend use of this implant in Type A and C, osteoporotic and periprosthetic fractures.
Keywords: Distal femur, DF-LCP, Lysholm score, Periprosthetic fracture
This document provides an introduction to guidelines for the surgical management of traumatic brain injury (TBI). TBI affects up to 2% of the population per year and is a major cause of death and disability, especially in young people. Intracranial hematomas complicate 25-45% of severe TBI cases and are the most important complication, as they can transform an otherwise mild injury into death or permanent disability if not treated effectively and promptly. The guidelines were created by a group of neurosurgeons to provide evidence-based recommendations for surgical management of post-traumatic intracranial mass lesions based on a review of over 700 publications from 1975-2001. However, there are no controlled clinical trials, so recommendations
This study aimed to develop a pre-operative risk scoring system to predict post-operative sepsis in HIV-infected surgical patients. The researchers analyzed data from 762 HIV-infected surgical patients in China. They developed a scoring system using five predictive variables: CD4 count, incision scale, surgical grade, opportunistic infections, and organ function. When validated on a separate dataset of 182 patients, the scoring system predicted post-operative sepsis with 95% sensitivity and 93.6% specificity. The researchers concluded the risk scoring system had high predictive accuracy and could help surgeons evaluate sepsis risk before operating on HIV-infected patients.
Background: Perforated tympanic membrane and middle ear infection are among common complications treated by tympanoplasty. This study was aimed to compare the effects of underlay and overlay tympanoplasty on the improvement of hearing and tympanic membrane landmarks and post-operative complications as well.
Sephaneous vein graft for anterior urethral stricutreDr. Manjul Maurya
El-Morsi et al. [10] first used a saphenous vein graft (SVG) in 1972 in 10 patients with promising results and suggested it as an alternative to Johanson staged urethroplasty, which was widely used at that time
ENDOSCOPIC TREATMENT OF PILONIDAL SINUS IN EGYPTIAN PATIENTSindexPub
Background: Treatment for pilonidal disease using minimally invasive methods is a reliable and successful alternative to conventional surgery, with quicker recovery, better cosmetic outcomes, and better pain management. The primary goals of this study are to assess the early outcomes of endoscopic pilonidal sinus treatment and to demonstrate the surgical approach and its adaptations. Materials and Methods: Our study was conducted on 30 patients with pilonidal sinus disease as a prospective cohort study for endoscopic treatment of the pilonidal sinus, from October 2021 to October 2022, in our surgical department at Theodor Bilharz Research Institute (TBRI). Surgical outcomes of sinus healing, pain, and discharge were reviewed in the outpatient clinic, and patient satisfaction levels were assessed through a standardized phone interview. Results: There were 24 males and 6 females, with a median age of 21.87±1.85 years (ranging from 16 to 57 years). The mean operative time was 44.17 (35-55) ±1.26 min. During the follow-up period of 24 weeks, wound closure was seen after a median of 4 weeks. Wounds were closed in 72% of patients after one month and 93% of patients after two months. 2 patients had to be re-operated due to failure: one had persistence of discharge, and the other had recurrence after 3 months. The satisfaction rate was 93.3%. Conclusions: Endoscopic pilonidal sinus treatment is a minimally invasive and cosmetically favorable procedure. To find out if it reduces recovery time and the long-term recurrence rate, a larger sample size and a longer follow-up are needed.
A 52-year-old female presented with a clear watery nasal discharge that worsened with bending over or coughing. Clinical tests and imaging found a CSF leak from the right cribriform plate, likely caused by increased intracranial pressure eroding the bone. CSF leaks can be managed conservatively or surgically via an endoscopic approach, which has high success rates and minimal morbidity compared to intracranial or extracranial approaches.
Tips and tricks to site and maintain nerve cathetersAmit Pawa
This lecture was given on Friday 13th September 2019 at the annual congress of the European Society of Regional Anaesthesia in Bilbao and Spain. The talk was also contributed to by the Twitter Community. Strategies and techniques to site, secure and maintain perineural nerve catheters is discussed
Balloon Assisted Coiling in Ruptured Cerebral AneurysmsDr Vipul Gupta
This document discusses balloon-assisted coiling techniques for treating ruptured cerebral aneurysms. It begins by outlining the historical use of balloons to treat broad-neck aneurysms using the "remodeling technique." It then provides details on techniques such as balloon selection and placement, aneurysm types best suited for different techniques, and potential complications. The conclusion is that balloon-assisted coiling is a versatile technique that does not increase complications compared to standalone coiling and can achieve better aneurysm occlusion, especially for difficult ruptured aneurysm cases.
Stent assisted reconstruction of difficult aneurysms in acute subarachnoid he...Dr Vipul Gupta
This document summarizes the experience of a single center in using stent-assisted reconstruction to treat difficult aneurysms in patients presenting with acute subarachnoid hemorrhage. It describes treating 35 aneurysms in 33 patients that were not amenable to standard coiling, balloon-assisted coiling, or surgery. Stent placement was used to support the neck of wide-neck or dissecting/blister aneurysms to avoid coil protrusion. Most patients (28 of 33) had good outcomes, while 2 had management morbidity and 3 died. The results demonstrate stent-assisted coiling is a viable option for challenging aneurysms in acute subarachnoid hemorrhage cases.
This study evaluated 52 cases of pediatric peritonitis treated via laparotomy over 5 years at a hospital in Nigeria. The most common cause of peritonitis was found to be typhoid intestinal perforation (48% of cases). Other common causes included ruptured appendix (17.3% of cases) and perforated intussusception (15.4% of cases). Post-operative complications occurred in 46.2% of patients, with surgical site infection being most common (23.1% of cases). The mortality rate was 13.5%. The study concludes that typhoid intestinal perforation is a major cause of peritonitis in children in this setting.
This document discusses new therapies for unruptured intracranial aneurysms, focusing on flow diverters. It provides background on flow diverters and how they work. The initial experiences with the Pipeline flow diverter are summarized from early clinical trials. Current controversies and limitations are discussed, including delayed aneurysm ruptures after treatment and questions around antiplatelet therapy. Ongoing studies are exploring real-world experiences to better understand safety and long-term outcomes of flow diverters.
This study investigated the clinical efficacy and safety of uniportal video-assisted thoracoscopic bronchial sleeve lobectomy (BSL) in 5 patients with central lung cancer. The results found that the BSL procedure was successfully completed in all 5 patients without severe complications. Key findings included an average operation time of 254 minutes, average blood loss of 116 ml, average hospital stay of 9.2 days, and no postoperative recurrence or metastasis during follow-up periods ranging from 3-19 months. The study concluded that uniportal video-assisted thoracoscopic BSL is a safe and minimally invasive treatment for central lung cancer.
This case report describes an unusual method for removing a plastic bead that had been aspirated into the tracheobronchial tree of a 9-year-old boy. Conventional bronchoscopic techniques using forceps were unsuccessful at removing the bead, which was located in the left lower lobar bronchus. A Fogarty embolectomy catheter was inserted through the bead's central hole and its balloon was inflated to grasp the bead. The catheter and bead were then removed together through the rigid bronchoscope, successfully retrieving the foreign body without requiring surgery. This creative use of a Fogarty catheter demonstrates how available tools can be adapted based on the shape and location of an aspirated foreign body.
Methods: Retrospectively, the file records of the patients who underwent sleeve gastrectomy were examined. Demographic features, Body Mass Index (BMI), the mouth opening, Mallampati score, thyromental distance, sternomental distance, neck circumference measurements and videolaryngoscopic examination results were recorded Results: In a total of 140 consecutive patients (58 male, 82 female) were included in the study. The mean age of the study participants was 35.40 ± 9.78 and the mean BMI of the patients was 44.33 ± 7.52 kg/m2
. The mean mouth opening of the patients was 4.82 ± 0.54 cm
and the mean neck circumference was 43.52 ± 4.66 cm. The mean thyromental distance was 8.02 ± 1.00 cm and the mean sternomental distance was16.58 ± 1.53 cm. Difficult intubation was determined in 8 (5.7%) patients. In logistic regression analysis, age (p : 0.446), gender (p : 0.371), BMI (p : 0.947), snoring (p : 0.567), sleep apnea (p : 0.218), mouth opening (p : 0.687), thyromental distance (p :0.557), sternomental (p : 0.596) and neck circumference (p : 0.838) were not the independent predictors of difficult intubation. However, Mallampati score (p : 0.001) and preoperative direct laryngoscopy findings (p : 0.037) performed in outpatient clinic were the significant
predictors of difficult intubation. Interestingly, all patients with grade 4 laryngoscopy findings had difficult intubation.
This study compared outcomes of laparoscopic appendectomy versus open appendectomy in 68 patients with acute appendicitis. Patients were divided into two groups - Group I underwent laparoscopic appendectomy while Group II underwent open appendectomy. The time to start oral feeding and average hospital stay were shorter in the laparoscopic group compared to the open group. Post-operative wound infections and abscesses were also less common in the laparoscopic group. The study concluded that laparoscopic appendectomy is an effective treatment for acute appendicitis compared to open appendectomy.
This study assessed the efficacy of different surgical techniques (open surgery, percutaneous nephrolithotomy [PNL], and retrograde intrarenal surgery [RIRS]) for treating kidney stones. 102 patients undergoing kidney stone surgery were divided into the three treatment groups. The mean stone burden, operative time, length of hospital stay, and residual stone rates were compared between groups. Complications like fever, infection, urine leakage and persistent pain were also assessed. PNL and RIRS had lower stone burdens, shorter operative times, shorter hospital stays, and fewer complications compared to open surgery. PNL and RIRS were found to be safer and more effective treatments for kidney stones than open surgery.
A comparative study of the effectiveness of Rubber band ligation and suture l...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Is routine thromboprophylaxis warranted in all patients of tibial fracture ma...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
This document discusses the debate around whether endovascular or surgical interventions should be the first option for treating critical limb ischemia in the lower extremities. It presents data on patency rates from studies comparing percutaneous angioplasty and stenting to femoral-popliteal bypass. It also summarizes studies reporting outcomes of endovascular and surgical procedures for various levels of the leg vasculature. The overall conclusion is that an endovascular-first approach is reasonable for appropriately selected patients, as it is not associated with worse outcomes compared to initial surgery.
This document provides instructions for central venous catheterization of the subclavian vein. It describes the indications, contraindications, necessary equipment, patient preparation, ultrasound guidance, procedure steps, potential complications, and references for central venous catheterization of the subclavian vein. The subclavian vein is the preferred site according to recent evidence. Ultrasound can help with placement despite bony landmarks. Key steps include identifying anatomic landmarks, local anesthesia, inserting the needle at a 30 degree angle, obtaining venous access, introducing the guidewire, dilating the vein, advancing the catheter over the wire, and securing the line. Potential complications include pneumothorax, hemothorax, and infection.
This study evaluated the experiences and outcomes of 150 patients who underwent single incision laparoscopic cholecystectomy (SILC) between 2009-2011. Two different techniques were used for the single incision procedure. The median operative time was 29 minutes. Patients were discharged after a median hospital stay of 1.33 days. Five patients developed superficial wound infections. Port site hernias developed in 5 patients within 6 months of surgery. No other major complications occurred. The study concluded that SILC is a safe procedure that can be performed successfully with conventional laparoscopic instruments and may provide advantages of reduced postoperative pain and improved cosmetic outcomes compared to traditional laparoscopic cholecystectomy.
Background: Distal femur fractures make up 6 to 7% of all femur fractures. Various plating options for distal femur fracture are conventional buttress plates, fixed-angle devices, and locking plates. This study was planned to evaluate and explore locking compression plate fixation in distal end femur fractures which is expected to provide a stable fixation with minimum exposure, early mobilization, less complications and a better quality of life.
Methods: The study was conducted as prospective clinical study in 20 skeletally mature patients with x-ray evidence of distal femur fracture fulfilling inclusion and exclusion criteria, operated with distal femur LCP plating. Patients were assessed radiologically and classified according to distal femur fracture classification and outcome graded as excellent, good, fair and poor based on Lysholm Knee Score.
Results: Out of 15 excellent outcome cases, 3 cases were type A1 fracture, 1 case had type A3, 2 cases had type B1 and B2 each, 5 cases had type C2 and 2 cases had type C3 fracture. 1 case with good outcome was type C3. 1 case with fair outcome was type B2. While 3 cases with poor outcome were type A1, A2 and C3.
Conclusions: The DF-LCP is an ideal implant to use for fractures of the distal femur. However, accurate positioning and fixation are required to produce satisfactory results. We recommend use of this implant in Type A and C, osteoporotic and periprosthetic fractures.
Keywords: Distal femur, DF-LCP, Lysholm score, Periprosthetic fracture
This document provides an introduction to guidelines for the surgical management of traumatic brain injury (TBI). TBI affects up to 2% of the population per year and is a major cause of death and disability, especially in young people. Intracranial hematomas complicate 25-45% of severe TBI cases and are the most important complication, as they can transform an otherwise mild injury into death or permanent disability if not treated effectively and promptly. The guidelines were created by a group of neurosurgeons to provide evidence-based recommendations for surgical management of post-traumatic intracranial mass lesions based on a review of over 700 publications from 1975-2001. However, there are no controlled clinical trials, so recommendations
This study aimed to develop a pre-operative risk scoring system to predict post-operative sepsis in HIV-infected surgical patients. The researchers analyzed data from 762 HIV-infected surgical patients in China. They developed a scoring system using five predictive variables: CD4 count, incision scale, surgical grade, opportunistic infections, and organ function. When validated on a separate dataset of 182 patients, the scoring system predicted post-operative sepsis with 95% sensitivity and 93.6% specificity. The researchers concluded the risk scoring system had high predictive accuracy and could help surgeons evaluate sepsis risk before operating on HIV-infected patients.
Background: Perforated tympanic membrane and middle ear infection are among common complications treated by tympanoplasty. This study was aimed to compare the effects of underlay and overlay tympanoplasty on the improvement of hearing and tympanic membrane landmarks and post-operative complications as well.
Sephaneous vein graft for anterior urethral stricutreDr. Manjul Maurya
El-Morsi et al. [10] first used a saphenous vein graft (SVG) in 1972 in 10 patients with promising results and suggested it as an alternative to Johanson staged urethroplasty, which was widely used at that time
ENDOSCOPIC TREATMENT OF PILONIDAL SINUS IN EGYPTIAN PATIENTSindexPub
Background: Treatment for pilonidal disease using minimally invasive methods is a reliable and successful alternative to conventional surgery, with quicker recovery, better cosmetic outcomes, and better pain management. The primary goals of this study are to assess the early outcomes of endoscopic pilonidal sinus treatment and to demonstrate the surgical approach and its adaptations. Materials and Methods: Our study was conducted on 30 patients with pilonidal sinus disease as a prospective cohort study for endoscopic treatment of the pilonidal sinus, from October 2021 to October 2022, in our surgical department at Theodor Bilharz Research Institute (TBRI). Surgical outcomes of sinus healing, pain, and discharge were reviewed in the outpatient clinic, and patient satisfaction levels were assessed through a standardized phone interview. Results: There were 24 males and 6 females, with a median age of 21.87±1.85 years (ranging from 16 to 57 years). The mean operative time was 44.17 (35-55) ±1.26 min. During the follow-up period of 24 weeks, wound closure was seen after a median of 4 weeks. Wounds were closed in 72% of patients after one month and 93% of patients after two months. 2 patients had to be re-operated due to failure: one had persistence of discharge, and the other had recurrence after 3 months. The satisfaction rate was 93.3%. Conclusions: Endoscopic pilonidal sinus treatment is a minimally invasive and cosmetically favorable procedure. To find out if it reduces recovery time and the long-term recurrence rate, a larger sample size and a longer follow-up are needed.
A 52-year-old female presented with a clear watery nasal discharge that worsened with bending over or coughing. Clinical tests and imaging found a CSF leak from the right cribriform plate, likely caused by increased intracranial pressure eroding the bone. CSF leaks can be managed conservatively or surgically via an endoscopic approach, which has high success rates and minimal morbidity compared to intracranial or extracranial approaches.
Vascular access for hemodialysis( AVF )Irfan Elahi
There are three main types of vascular access for hemodialysis: arteriovenous fistulae (AVF), arteriovenous grafts, and catheters. AVFs have the lowest rate of failures and complications and are the preferred type of access.
For an AVF to be suitable for cannulation and dialysis, it must undergo a maturation process where the fistula develops adequate blood flow, wall thickness and diameter. A properly matured fistula will have a minimum diameter of 6mm, be less than 6mm deep, have a blood flow over 600ml/min, and be evaluated at 4-6 weeks after creation.
The physical exam is the best tool to determine if an AV
This document discusses the history and development of ultrasound-guided needle procedures from the 1960s onwards. It notes that while early studies showed minor risks, later reviews found complication rates up to 0.9% with some mortality. The document outlines key aspects of performing biopsies safely and effectively using ultrasound guidance, including appropriate patient preparation, informed consent, needle choice, and specimen handling. It emphasizes the importance of real-time visualization to target lesions precisely while avoiding vital structures.
Medical thoracoscopy (MT) is a minimally invasive procedure that uses rigid or semi-rigid thoracoscopes to directly visualize the pleural surfaces. It has diagnostic and therapeutic applications. The document discusses the history, techniques, indications, and innovations of MT. It notes that MT has a high diagnostic yield for conditions like tuberculosis and malignancies. Local anesthesia with conscious sedation is commonly used. Complications can include infection, bleeding, and re-expansion pulmonary edema. Ongoing studies are exploring modifications to MT techniques and applications in complex parapneumonic effusions.
This document discusses central venous catheters. It describes central lines as flexible tubes inserted into large veins near the heart to deliver fluids, medications, blood products, and monitor central venous pressure. It outlines different types of central lines including non-tunneled, tunneled, and implanted ports. The document discusses indications, contraindications, complications, and proper insertion and maintenance techniques to prevent infections like chlorhexidine skin antisepsis and dressing changes. The goal is to promote infection prevention best practices for central lines.
This document discusses central venous catheters. It describes central lines as flexible tubes inserted into large veins near the heart to deliver fluids, medications, blood products, and monitor central venous pressure. It outlines different types of central lines including non-tunneled, tunneled, and implanted ports. The document discusses indications, contraindications, complications, and proper insertion and maintenance techniques to prevent infections like chlorhexidine skin antisepsis and dressing changes. The goal is to promote infection prevention best practices for central lines.
A biopsy is a surgical procedure to obtain tissue samples for microscopic examination and diagnosis. The main types of biopsies are cytology, aspiration, incisional, and excisional. Cytology examines individual cells but cannot provide histologic details, while aspiration uses a needle to remove fluid or cells. Incisional biopsies remove a portion of tissue, while excisional biopsies completely remove small lesions. Proper biopsy techniques aim to obtain representative tissue samples while avoiding thermal or mechanical damage. Careful documentation and handling of specimens aids pathological examination and diagnosis.
Overall, catheter related bloodstream infection (CRBSI) occurs in approximately 3% of catheterizations, with the highest rates seen in dialysis catheters. The major cause of infection during the first weeks is from skin microorganisms entering through the catheter hub or lumen. Diagnosis requires signs of infection at the insertion site, symptoms of bloodstream infection, and matching organisms growing from catheter and blood cultures. Treatment involves removing unnecessary catheters and treating with antibiotics based on the isolated organism. Strict hand hygiene and aseptic techniques during insertion and maintenance can help prevent CRBSI.
1) Al-Zahrawi, an 11th century Arab physician, is considered the first to perform a needle biopsy of the thyroid gland using hollow needles.
2) In the late 19th century, the terms "biopsy" and "bioscopy" were introduced into medical terminology to describe the microscopic examination of living tissue samples.
3) Over the past century, the use of biopsy has evolved from an occasional procedure performed on living organs to a widely adopted diagnostic tool used across many clinical specialties to characterize lesions and diseases.
The document discusses various aspects of biopsy procedures including:
1. Biopsy is the removal of tissue for microscopic examination and diagnosis to help establish a histological diagnosis, prognosis, and treatment plan.
2. There are various biopsy techniques including incisional, excisional, punch, and aspiration biopsies. Each have advantages and disadvantages for different clinical situations.
3. Proper biopsy technique and handling of specimens is important to avoid artifacts and allow for an accurate histological assessment.
The document discusses various aspects of the medical laboratory workflow process and phlebotomy procedure. It covers topics like patient registration, requisition forms, specimen collection, coding and billing, laboratory information systems, and the venipuncture procedure. The venipuncture procedure is described in detail in multiple steps, including greeting the patient, verifying patient identification, selecting a vein site, preparing the site, inserting the needle, drawing blood into tubes, removing the needle, and finishing up. Patient identification is stressed as the most critical part of phlebotomy. Risks of phlebotomy to patients and health workers are also reviewed.
The document discusses complications that can arise with arteriovenous (AV) access for hemodialysis and their management. It covers types of complications such as hematomas, significant steal syndrome, non-maturing fistulas, venous outflow stenosis, aneurysmal degeneration, and central venous stenosis. It describes techniques for managing these complications, including balloon angioplasty, coil embolization, stent graft placement, and open surgery. The overall message is that timely intervention is important to address access complications in order to maintain patency and usability of AV access for hemodialysis.
The document discusses complications that can arise with arteriovenous (AV) access for hemodialysis and their management. It covers types of complications such as hematomas, significant steal syndrome, non-maturing fistulas, venous outflow stenosis, aneurysmal degeneration, and central venous stenosis. It describes techniques for managing these complications, including balloon angioplasty, coil embolization, stent graft placement, and open surgery. The overall message is that timely intervention is important to address access complications in order to maintain patency and usability of AV access for hemodialysis.
Automation in biochemistry, Micro biology and Hematology of 21st centuryVamsi kumar
The document is an internship report submitted by Attuluri Vamsi Kumar to the Department of Medical Laboratory Technology at Loyola College in Chennai, India. It details his internship experience at the Southern Railway Headquarters Hospital in Perambur, Chennai. The report includes sections on phlebotomy/sample collection, hematology, biochemistry, microbiology, and blood banking/serology. It provides information on performing phlebotomy properly, including patient preparation, vein selection, blood collection techniques, and potential complications.
The document discusses proper procedures for blood collection, including using universal safety precautions when handling needles and blood samples, selecting appropriate veins for venipuncture, collecting blood in tubes containing anticoagulants to prevent clotting, and taking care when collecting from babies or doing fingersticks to obtain small blood samples. Common anticoagulants added to blood collection tubes are EDTA, sodium citrate, heparin, and double oxalate, which work by binding calcium ions or inhibiting coagulation factors to prevent clotting.
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine
Al-Azhar University. Oral biopsy; why, when, and how? Biopsy is the removal of the tissue from the living organism for the purpose of microscopic examination and diagnosis. Looking for a definitive diagnosis is the aim of biopsy. Types of Biopsy include incisional, excisional, drill, fine needle and frozen section biopsy.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Congestive Heart failure is caused by low cardiac output and high sympathetic discharge. Diuretics reduce preload, ACE inhibitors lower afterload, beta blockers reduce sympathetic activity, and digitalis has inotropic effects. Newer medications target vasodilation and myosin activation to improve heart efficiency while lowering energy requirements. Combination therapy, following an assessment of cardiac function and volume status, is the most effective strategy to heart failure care.
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7shruti jagirdar
Unit 4: MRA 103T Regulatory affairs
This guideline is directed principally toward new Molecular Entities that are
likely to have significant use in the elderly, either because the disease intended
to be treated is characteristically a disease of aging ( e.g., Alzheimer's disease) or
because the population to be treated is known to include substantial numbers of
geriatric patients (e.g., hypertension).
This presentation gives information on the pharmacology of Prostaglandins, Thromboxanes and Leukotrienes i.e. Eicosanoids. Eicosanoids are signaling molecules derived from polyunsaturated fatty acids like arachidonic acid. They are involved in complex control over inflammation, immunity, and the central nervous system. Eicosanoids are synthesized through the enzymatic oxidation of fatty acids by cyclooxygenase and lipoxygenase enzymes. They have short half-lives and act locally through autocrine and paracrine signaling.
PGx Analysis in VarSeq: A User’s PerspectiveGolden Helix
Since our release of the PGx capabilities in VarSeq, we’ve had a few months to gather some insights from various use cases. Some users approach PGx workflows by means of array genotyping or what seems to be a growing trend of adding the star allele calling to the existing NGS pipeline for whole genome data. Luckily, both approaches are supported with the VarSeq software platform. The genotyping method being used will also dictate what the scope of the tertiary analysis will be. For example, are your PGx reports a standalone pipeline or would your lab’s goal be to handle a dual-purpose workflow and report on PGx + Diagnostic findings.
The purpose of this webcast is to:
Discuss and demonstrate the approaches with array and NGS genotyping methods for star allele calling to prep for downstream analysis.
Following genotyping, explore alternative tertiary workflow concepts in VarSeq to handle PGx reporting.
Moreover, we will include insights users will need to consider when validating their PGx workflow for all possible star alleles and options you have for automating your PGx analysis for large number of samples. Please join us for a session dedicated to the application of star allele genotyping and subsequent PGx workflows in our VarSeq software.
The biomechanics of running involves the study of the mechanical principles underlying running movements. It includes the analysis of the running gait cycle, which consists of the stance phase (foot contact to push-off) and the swing phase (foot lift-off to next contact). Key aspects include kinematics (joint angles and movements, stride length and frequency) and kinetics (forces involved in running, including ground reaction and muscle forces). Understanding these factors helps in improving running performance, optimizing technique, and preventing injuries.
Pictorial and detailed description of patellar instability with sign and symptoms and how to diagnose , what investigations you should go with and how to approach with treatment options . I have presented this slide in my 2nd year junior residency in orthopedics at LLRM medical college Meerut and got good reviews for it
After getting it read you will definitely understand the topic.
Gene therapy can be broadly defined as the transfer of genetic material to cure a disease or at least to improve the clinical status of a patient.
One of the basic concepts of gene therapy is to transform viruses into genetic shuttles, which will deliver the gene of interest into the target cells.
Safe methods have been devised to do this, using several viral and non-viral vectors.
In the future, this technique may allow doctors to treat a disorder by inserting a gene into a patient's cells instead of using drugs or surgery.
The biggest hurdle faced by medical research in gene therapy is the availability of effective gene-carrying vectors that meet all of the following criteria:
Protection of transgene or genetic cargo from degradative action of systemic and endonucleases,
Delivery of genetic material to the target site, i.e., either cell cytoplasm or nucleus,
Low potential of triggering unwanted immune responses or genotoxicity,
Economical and feasible availability for patients .
Viruses are naturally evolved vehicles that efficiently transfer their genes into host cells.
Choice of viral vector is dependent on gene transfer efficiency, capacity to carry foreign genes, toxicity, stability, immune responses towards viral antigens and potential viral recombination.
There are a wide variety of vectors used to deliver DNA or oligo nucleotides into mammalian cells, either in vitro or in vivo.
The most common vector system based on retroviruses, adenoviruses, herpes simplex viruses, adeno associated viruses.
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
Nutritional deficiency Disorder are problems in india.
It is very important to learn about Indian child's nutritional parameters as well the Disease related to alteration in their Nutrition.
TEST BANK For Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 14...Donc Test
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Butenhole
1. Buttonhole cannulation of arteriovenous fistulas in the United States
Tushar J. Vachharajani1,2, Leslie Wong1,2, Vandana D. Niyyar3, Kenneth D. Abreo4,
Michele H. Mokrzycki5,6
1Department of Nephrology & Hypertension, Cleveland Clinic Lerner College of
Medicine of Case Western Reserve University, Cleveland, Ohio
2Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland,
Ohio
3Departments of Medicine and Divisions of Nephrology, Emory University School of
Medicine, Atlanta, Georgia
4Louisiana State University Health Sciences Center, Shreveport, Louisiana
5Montefiore Medical Center, Bronx, New York
6Albert Einstein College of Medicine, Bronx, New York
Corresponding author:
Tushar Vachharajani, MD, FASN
Glickman Tower –Q7
9500 Euclid Ave
Cleveland, OH 44195
vachhat@ccf.org
@tvachh
Kidney360 Publish Ahead of Print, published on March 6, 2020 as doi:10.34067/KID.0000052020
Copyright 2020 by American Society of Nephrology.
2. Abstract
The cannulation technique of a hemodialysis vascular access has remained
controversial with differing viewpoints. The quality of dialysis, overall patient safety and
individual dialysis experience often dictate the type of cannulation technique used in
clinical practice. The three commonly used techniques to access a hemodialysis
vascular access are the rope-ladder, area and buttonhole. Even though the buttonhole
technique has been around since mid-1970’s, the dialysis community remains divided
on its suitability for routine use to provide maintenance hemodialysis therapy. The
proponents of this technique value the ease of cannulation with less pain and discomfort
while the opponents highlight the increased risk of infection. The actual clinical evidence
from the United States is limited and remains inconclusive. The current review provides
an overview of the available experience from the United States, highlighting the correct
technique of creating a buttonhole, summarizing the current evidence and
recommending a need for larger randomized controlled studies in both in-center and
home hemodialysis population.
3. History of buttonhole cannulation technique:
A well-functioning vascular access is essential to provide adequate maintenance
hemodialysis. Once the initial barriers to creating an arteriovenous fistula (AVF) are
crossed, its long-term patency depends on regular monitoring for signs of dysfunction
with timely intervention, proper cannulation technique, and minimizing common
complications such as thrombosis, infection and aneurysm formation. Additionally,
patient factors such as pain during cannulation and aesthetics often dictate the selection
of a cannulation technique. The three frequently used cannulation techniques in clinical
practice are described as ‘rope-ladder’ (RL), ‘area’ and ‘buttonhole’ (BH). The RL or
different site technique involves sequentially using a different site to place two needles
during consecutive dialysis sessions. In area or cluster technique, the needles are
placed in the same area while with BH or ‘constant site’ technique the needles are
placed at a constant site through a subcutaneous tunnel/tract at consecutive dialysis
treatments (Figure 1).
The BH technique was first described in the Polish literature in 1977 as a “constant site”
method and was used serendipitously for a patient who had a short cannulation
segment (1, 2, 3). The method was observed to be less painful by the patient leading to
a first publication of experience with16 cases in 1979 (4). Subsequently, comparing
constant site to standard method in 10,000 dialysis sessions, positive patient
experiences such as easy and quick cannulation, less pain and 10-fold reduced
hematoma formation were observed. In 1984, Kronung coined the term “buttonhole
puncture” for constant site technique (5).
4. The use of blunt needles instead of sharp beveled needles also resulted as a pure
coincidence. In the past, the needles were reused routinely leading to blunting of the
sharp edge. The dull needles were found to cause minimal trauma to the established
subcutaneous tract during cannulation (2).
Early experiences and enthusiasm:
There is a paucity of data detailing the use of the BH cannulation in the United States.
The groups from Washington and Oregon were pioneers in adopting this technique,
which gradually spread to a few centers across the country (6). The BH method was
often considered in patients with short cannulation segments, and self-cannulating
patients. Early enthusiasm with using this technique was mainly due to the potential
advantages identified in the earlier reports from Poland (1, 4). About 38% of the centers
from the region were utilizing the buttonhole technique (7). In one facility, buttonhole
cannulation reduced the infiltration rate from 7% to 0% and decreased hemostasis time
from 8 minutes to 5 minutes as compared to the RL method, without any increase in
infection rates, need for angioplasty intervention or observable aneurysm formation at
the cannulation sites. A patient satisfaction survey reported that 100% of the patients
using BH method felt decreased discomfort and pain compared to RL method with
sharp needles. The staff members expressed satisfaction as using blunt needles
reduced the risk of needle stick injury (7).
Another survey from the same region sent to all 61 patients using BH technique, had a
75% response rate with 70% experiencing less pain and 20% equivocal as compared to
5. RL technique. Furthermore, 63% felt that it took less time to insert buttonhole needles
as compared to conventional needles. Overall, patients reported that their arms looked
better, scabs were smaller with faster healing. The researchers also found that there
was a substantial decrease in infections, missed sticks and infiltrations.
Buttonhole technique:
Indications-
Buttonhole cannulation is usually selected for AVFs with a short cannulation segment or
because of patient preference. Buttonhole creation and cannulation can be
accomplished by the patient or nurse in the in-center hemodialysis (HD) unit and by the
patient or caregiver with home hemodialysis (HHD) (8). (Figures 3 and 4, List 1).
Steps for buttonhole creation-
1. Goal: The goal of buttonhole cannulation is to develop two fibrous tracts from the
skin surface into the AVF that can be repeatedly cannulated with blunt needles.
2. Choosing the BH sites: A straight segment of the AVF is selected for cannulation.
Curves, flat spots and aneurysms of the AVF are avoided. The arterial needle
cannulation site is usually located few inches proximal to the arterial anastomosis
of the AVF. The needle entry sites are spaced at least 2-3 inches apart.
3. Cannulating with sharp needles to create BH: The cannulator should wear a
facemask as it prevents the spread of bacteria during the disinfection and
cannulation steps. Both hands of the cannulator and the access site are
thoroughly cleaned with antibacterial soap. The access extremity is positioned
comfortably, lighting should be good and glasses worn if needed. A tourniquet is
6. placed over the AVF above the cannulation site to enlarge the AVF. The direction
of the needle and choice of the buttonhole site is dictated by the patient in the
self-cannulation method. The needle tip is aligned over the cannulation site with
the bevel up. The skin puncture site should be at a distance of 3-5 mm from the
AVF creating a short subcutaneous tunnel (Figure 1 and 2). The skin over the
AVF is pulled side ways to make it taut and the AVF is cannulated at an angle
appropriate for the depth of the vein (usually 20-250). When a flash back is
observed, the insertion angle is lowered and the needle is slowly advanced. The
needle is never inserted so far that the hub of the needle is touching the insertion
site.
4. Subsequent cannulations with sharp and blunt needles: A face mask is worn and
the access site and hands are cleaned as described above. Scabs are removed
from the buttonholes (described in the next section) followed by repeat
disinfection of the access sites prior to needle insertion. Sharp needles are
introduced at the two selected sites, at the same angle, in the same direction and
at the same depth with each cannulation by the same cannulator for
approximately 6-10 cannulations until the fibrous tracts are formed. Cannulation
with blunt needles is then attempted through the BH sites by the same
cannulator.
5. Disinfection and scab removal: Disinfection of the skin and BH sites is a very
important step to prevent infections (9). BH sites are disinfected with an
approved disinfecting agent, such as 2% chlorhexidine gluconate / 70 %
isopropyl alcohol, betadine/povidone iodine, 70% alcohol, sodium hypochlorite,
7. (follow manufacturers recommendations on contact time). Enough time should be
allowed for the scab to soak and soften for easy removal. A different swab is
used to disinfect each site. Following disinfection, it is important that scabs in the
BH are removed. Scabs are formed from blood entering the fibrous tract after
needles are removed. Scabs can be colonized by skin flora such as
Staphylococcus aureus, and cause blood stream infections if not removed. If the
scabs are not dislodged during the initial disinfection process, they should be
further softened with a gauze soaked in saline, water or antibacterial soap or an
alcohol pad. To loosen the scabs, he skin is stretched in all four directions
around each site and scabs are removed completely using a sterile gauze or
scab removal device (comes with blunt needles). The scab removal device is
inserted at the edge of each scab and the scab is dislodged. Others have
described non-invasive methods of scab removal using a shower scrubber or an
exfoliating facial sponge and antibacterial soap for scab removal (10). Needles
should not be used to remove the scab as sharp needles could cut into the skin
and cause infection or oozing. After scab removal, the BH sites should be
disinfected again as the scab harbor bacteria, which may spread during the scab
removal process. Topical anesthetics and subcutaneous lidocaine to numb the
area before the cannulation procedure should be avoided. The use of these
products may cause scarring, vasoconstriction and keloid formation making
needle insertion more difficult.
6. Buttonhole site care post-cannulation: Calcium mupirocin 2% ointment can be
applied directly to BH and allowed to dry with no bandage after needle removal
8. and has been shown to decrease infections (11). Applying a polysporin or
betadine gauze pad over the buttonhole sites for a minimum of six hours after
needle removal has also been shown to reduce infections (12).
Techniques to form predictable BH
Toma et al (13) have described a time-saving method to create a buttonhole tract using
thumbtack-shaped polycarbonate peg (BioHole™ Plug) that is inserted into the access
vessel along the same path as the puncture needle that has just been removed. Then,
at the beginning of the next HD, the peg is removed and a blunt puncture needle is
inserted along the track already formed by the peg left in place. This buttonhole
puncture approach was used by Toma in 37 patients for 3 months, no significant
bleeding was noted during HD and only one patient had enough erythema at the
puncture site to suggest possible infection.
Marticorena has described the use of Supercath Clampcath SP 502® hemodialysis
needle combined with an overlying polyurethane catheter left indwelling after dialysis for
10 days in 12 patients (14). The hemodialysis needles were 17G, 1 in. long Clampcath
SP 502® (Togo Medikit Co. Ltd., Miyazaki, Japan). The Clampcath® catheters were
inserted as arterial and venous needles for the first dialysis, at selected sites. The
needles were removed and the polyurethane catheters were secured with Steri‐Strips®
(3M Health Care, St. Paul, MN, USA) and the skin entry site was covered with a 2 × 2
sterile gauze with Polysporin® (Pfizer Canada Inc., Markham, ON, Canada)
antibacterial ointment and covered with Tegaderm® (3M Health Care) dressing. Post-
9. dialysis, the catheters were flushed with 10mL of normal saline and then 0.6 mL of
citrate 4% was instilled into each lumen. At the end of the dialysis performed on the
10th day, both polyurethane catheters were removed. Blunt needles were used for the
next dialysis treatment using all the antiseptic precautions. Successful buttonholes were
created in 11 of 12 patients after 10 days. Pain scores for the first blunt needle
cannulation with this technique was significantly less than with the classical technique.
Following this report, two cases of fracture and dislodgement of the Supercath
Clampcath when used for making buttonholes have been described, raising concerns
for the safety of this technique (15,16).
Data from US centers
One of the first U.S. experiences with BH use was published by Ball et al in 2007, from
4 in-center HD facilities located in Washington and Oregon (7). In one HD center, which
compared BH use (N=25) to rope-ladder (RL) (N=17), there was no difference in access
infection or in interventions for stenosis/thrombosis between the groups. Access
infiltrations and time to hemostasis were lower in the BH group. No aneurysms formed
in the BH group. In the second HD center, access infections and infiltrations were lower
using BH compared to RL, as self-reported by a patient survey (N=61). In the remaining
two HD centers (BH patients: N=13, and N=14), access infections occurred in 8% and
21% of AVFs using the BH technique. However, no comparator data for concurrent RL
complications was provided from these 2 units. Unfortunately, in this publication the
duration of patient follow-up was not provided, and measured outcomes and definitions
were not standardized among HD facilities.
10. In 2010, Birchenough et al. reported a markedly higher rate of access infection using
BH technique in a single-center report from a HD facility in New York (17). Data from
both in-center and home hemodialysis (HHD) patients was collected retrospectively
over a 13-month period prior to the implementation of a quality improvement project. In
this initial period, access infection occurred in 52% patients using the BH and 5% using
RL. After a revised BH policy and procedure was introduced, there was a reduction in
access infection associated with BH to 30% in a 14-month follow-up period. No infection
data were provided for the RL technique in this post-quality improvement period. Data
about other complications such as aneurysm, access interventions and access
infiltration was not provided, nor was the definition of access infection and or data about
the total number of BH and RL patients.
In 2014, Chan et al compared complications over a 1-year period associated with the
BH and RL techniques from a single center in Wisconsin, using a prospectively
collected database (18). Patient demographic and clinical characteristics were similar
between the BH (n=45) and RL (n=38) groups, with the exception of diabetes mellitus,
which was more prevalent in the BH group (69% vs. 34%, p=0.002). There were
similar bacteremia rates (BH 11% vs. RL 8%, p=0.62) between the techniques.
Bacteremia was defined as at least 1 positive blood culture with definite or probable
association with infection secondary to the AVF. No data were provided for local access
infections. In a multivariate analysis, there was similar primary patency at 3, 6, and 12
11. months (HR=1.22, (95% CI, 0.65-2.28; p=0.53), and similar number of access
interventions (BH 64% vs. RL 71%. p=0.52).
A low incidence of access infection with BH cannulation was reported in a small single-
center, retrospective study in a pediatric in-center dialysis population in Missouri (19). In
2019, Moore et al retrospectively reviewed data in 14 patients using BH technique over
11 years. Mean follow-up was 15 months (range 3-58 months). There was only 1 local
access infection with Staphylococcus aureus. No other outcomes were reported.
In contrast, Lyman et al (20) reported a significantly higher risk of vascular-access
related infections associated with BH cannulation in U.S. patients on hemodialysis
treated in the outpatient dialysis centers (5). A retrospective observational study was
performed using data from the National Healthcare Safety Network (NHSN) surveillance
report from 2013-2014. In 2014, 9% (n=271,980) of all AVF patient-months reported to
NHSN were among BH patients. During the study period, there were 2,466 access-
related blood stream infections, 3,169 local access site infections and 13,726
intravenous antimicrobial initiation in HD patients using the BH cannulation technique.
Hospitalization occurred in 37% of patients with access-related blood stream infections.
After adjusting for facility characteristics and practices, buttonhole cannulation was
associated with significantly higher risk of access-related bloodstream infection
(aRR=2.6, 95% CI=2.4-2.8) and local access site infection (aRR=1.5, 95% CI=1.4-1.6),
but was not associated with increased risk of intravenous antimicrobial start.
12. The available U.S. data, albeit limited, favor a reduced risk of aneurysm formation using
BH technique. The initial studies from centers in the Pacific Northwest in 2007 reported
no aneurysms with BH use (7). In 2011, Pergolotti et al reported a lower rate of
aneurysm formation using the BH technique (21). This study included 45 patients (21
using BH and 24 using RL technique) who were dialyzing at an in-center HD facility in
New York, and who were followed over a 4-month period. Aneurysms were observed in
20% of patients using the BH technique and 46% using the RL method. The authors
state that preexisting AVF aneurysms were present before BH technique was initiated in
this group, therefore overestimating the incidence of aneurysm formation attributable to
BH.
Data from centers outside US
The experience from non-US centers has been very different. In 2014, MacRae et al in
a randomized controlled trial with 140 patients reported no difference in AVF survival
(RR=1.04; 95% CI 0.81, 1.34) and no difference in pain between buttonhole and rope
ladder cannulation technique. The risk of serious AVF related Staphylococcus aureus
bacteremia was significantly higher with buttonhole compared to rope ladder method at
1-year, (13% vs. 0% respectively; RR=19; 95% CI: 8, 46) (24). Muir et al reviewed 90
consecutive home hemodialysis patients trained in buttonhole cannulation method. The
total AVF infection rate was higher with the use of buttonhole method (incidence ratio
3.85; CI 1.66, 12.77; p=0.03). Additionally, a systematic review of 4 randomized and 7
observational trials, the authors found AVF related infections to be increased with
buttonhole method compared to rope ladder method. (RR 3.3; 95% CI 0.91, 12.20) (26).
13. Patient satisfaction, pain with cannulation, need for surgical or endovascular
intervention was statistically not different between BH and RL.
Perspectives from the front lines
The 2020 Vascular Access Guidelines from the National Kidney Foundation Kidney
Disease Outcome Quality Initiative considers it reasonable to limit BH only to special
circumstances given the associated increased risks of infection and related adverse
consequences. Moreover, BH cannulation refers only to AVF. Arteriovenous grafts
should not be accessed by BH cannulation due to risk of pseudoaneurysm and “one-
siteitis” (22). The guideline was justified based on international data analyzed from
several randomized control trials and observational studies comparing BH versus RL
cannulation technique (23 -26).
The issue of whether the renal community should support or discourage the use of
buttonhole cannulation is highly dependent on the vantage point of the party involved
(27-29). Patients may rate their experiences with BH technique favorably compared to
RL technique, with reduced pain, compression time, oozing, re-bleeding, and ease of
use (24). Fear of pain and discomfort (needle phobia) is a widely-accepted barrier to
self-cannulation by patients, and by extension, ability of patients to be trained to perform
HHD (28). The preponderance of currently available evidence shows an increased risk
of infectious complications, leading some experts to advocate strongly against use of
BH cannulation from a harm prevention standpoint (29, 30). However, it remains unclear
if objective scientific evidence is strong enough to supersede patient autonomy to
14. choose a riskier, but more personally acceptable option, provided technique and
infection control are followed consistently.
Due to the subjective nature of individual life priorities, each informed discussion
between clinicians and patients should take into account that the relative weight of
outcomes differs between patients, some who may be willing to accept a higher risk of
infections in exchange for ease of self-cannulation or less perceived pain or discomfort.
What is poorly described are perceptions of practicing nephrologists and advanced
practice providers in the community. Recently, Nephrologists Transforming Dialysis
Safety Initiative of the American Society of Nephrology (NTDS of ASN) held a focus
group session at the American Society of Nephrology Kidney Week 2019 asking if BH
cannulation technique should be taught to HHD and in-center HD patients (31). Table 1
lists selected comments. Some expressed a perception that the large dialysis
organizations either did not allow or did not recommend BH technique for in-center HD.
Other respondents indicated that owing to lack of qualified dialysis staff, patients using
BH admitted to the hospital were often switched to sharp needles. An additional concern
was that some nephrologists had very little or no experience with HHD and were not as
familiar with the infection controversies in buttonhole use.
While the BH data reported by Canada, the United Kingdom and other countries is
likely generalizable to the U.S., systemic and cultural health care factors unique to
U.S. hemodialysis population may further influence the risk of infection (32,
33). Existing differences between the U.S. and Canada that may impact on BH
15. outcomes include differences such as patient to nurse staffing ratios, training/education
of staff (AVF cannulation by registered nurses versus patient care technicians), hospital-
based versus free-standing hemodialysis facilities, local provider expertise in managing
self-cannulation issues, and patient selection for HHD. There is a need for future,
adequately powered, randomized control trials from U.S. hemodialysis centers, to
provide long-term, prospectively collected data and to adequately assess the risk and
benefits of BH use in both in-center HD and HHD patients in the U.S.
Future research needs and potential
Since staff and patient training and ongoing care for BH cannulation will be strongly
influenced by policies and procedures of dialysis providers, future efforts to collect and
understand data on practice patterns and outcomes might benefit from a collaborative
strategy by stakeholders. The authors of this review contacted five major U.S. dialysis
organizations, Fresenius Kidney Care, DaVita, Dialysis Clinic Inc., Satellite Healthcare,
and Northwest Kidney Centers, but none of these providers had data specific to BH-
related blood stream infections or access-related infections that could be studied versus
RL technique. Fresenius reported infection prevention in HHD patients is a major focus,
with review of BH cannulation outcomes, dissemination of best practices, and adoption
of a centralized access management system are ongoing (D. Chatoth, personal
communication, October 2019). DaVita is similarly monitoring BH-associated infection
rates, has implemented a topical mupirocin prophylaxis protocol, and incorporated
mandatory access care technique observation as part of HHD clinic visits (M. Schreiber,
16. personal communication, October 2019). Hopefully more granular details related to
these approaches to buttonhole cannulation will be available as more data is collected.
Summary
In summary, it is difficult to draw firm conclusions about BH risks in the U.S. population
based on these limited data. There are no large prospective randomized controlled
trials comparing complications using BH to RL technique from U.S. hemodialysis
centers. With the exception of the review of the NHSN data (20), most of the available
U.S. data on this topic are derived from small, single-center cohorts. The follow-up
periods are of relatively short-duration and outcomes not well defined using standard
criteria. Most of the existing U.S. data is for patients dialyzing in-center, and minimal
evidence exists about the HHD population.
17. Disclosures
The authors have nothing to disclose.
Acknowledgments
This work was a product of the authors’ participation in the Vascular Access Workgroup
of the Nephrologists Transforming Dialysis Safety Initiative of the American Society of
Nephrology.
Author Contributions
T Vachharajani: Conceptualization; Data curation; Writing - original draft; Writing -
review and editing
L Wong: Data curation; Writing - original draft
V Niyyar: Data curation; Writing - original draft
K Abreo: Data curation; Writing – original draft; Writing - review and editing
M Mokrzycki: Conceptualization; Data curation; Writing - original draft; Writing - review
and editing
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20. Category Response from focus group participant
Patient
Selection
“It needs to be the right patient at the right time.”
“Home patients are more attentive.”
“Currently patients who dialyze at home are in the top tier of self-
motivation and are currently self-selected. As we increase home
dialysis, it will be essential to adapt current practices to allow for
more patients who [may not fit these criteria].”
Modality
Specific
“Fewer patients would be able to choose home if they can’t use
buttonholes.”
“Buttonholes should not be created for in-center patients, there is
a lot of infection historically, but it’s okay for home patients.”
Technique and
Training
“There should be a checklist for buttonhole cannulation.”
“Multiple cannulators increase the risk of infection, for example,
when there is an in-center creation by clinic staff before the patient
is sent home.”
“Strict aseptic technique needs to be followed (do not use “scab
removers”).”
Best Practices
Guidance
“NTDS should create a buttonhole registry.”
“If NTDS would come up with a position or recommendations on
using buttonholes, [we] would go with that.”
Table 1: Nephrologists Transforming Dialysis Safety Focus Group responses
from nephrologists and advanced practice providers
21. List 1 - Summary of key elements for buttonhole cannulation of arteriovenous
fistula
1. Ideal patient selection
2. Preferably a single cannulator to create the subcutaneous tract
3. Follow strict asepsis protocol during cannulation and decannulation
4. Use sharp needle only until the subcutaneous tract is created
5. Only use blunt needles for subsequent cannulations
6. Protocolize pre- and post-cannulation steps